V O L . 1 . | I S S U E 1 | J U N E 2 0 2 0 PUBLIC HEALTH & ENVIRONMENT BULLETIN

D I R E C T O R A T E O F P U B L I C H E A L T H A N D E N V I R O N M E N T

THEME: KAMPALA'S HEALTH AND ENVIRONMENT IN THE MIDST OF COVID-19

IN THIS ISSUE

01 EXECUTIVE DIRECTOR'S 12 PUBLIC HEALTH MESSAGE EMERGENCIES

13 HEALTH EVENTS 02 PUBLIC HEALTH & ENVIRONMENT SANITATION & DIRECTOR'S MESSAGE 14 ENVIRONMENT 03 MEDICAL SERVICES 18 INFORMATION & COMMUNICATIONS TECHNOLOGY (ICT)

09 POLLUTION & AIR 20 ACKNOWLEDGEMENTS QUALITY

https://www.kcca.go.ug | 0800 99 00 00 | [email protected] | @kccaug | @kccaug M E S S A G E S

Executive Director's Message Editorial Team's Message

We are aware of the many hardships that this unusual Dear Reader, and difficult time of COVID-19 and lockdowns has We welcome you to the inaugural volume and issue of presented to our environment, public health services, the KCCA-Public Health and Environment Bulletin. businesses and lifestyles. It is important now more than ever we all work together and support each other. The main aim of this Bulletin is to document and communicate the works, achievements, and key Together, we not only set out to deliver quality challenges with regards to Kampala’s Public Health, services to the people of Kampala with an accountable Environment and other related events. The end goal is to and admirable image, we also set out to build capacity to disseminate this information to the policy makers, health prepare, respond and manage all public health threats or professionals, the public, implementing partners and all related events, COVID-19 inclusive. stakeholders.

In this issue, we are excited to share with you a wide There are encouraging signs countrywide with low variety of articles focusing on Kampala’s health and community transmission, no deaths and remarkable environment in the midst of COVID-19 including: articles recoveries. We can comfortably attribute these positive on medical services, environment, sanitation, pollution indicators to our efforts towards preventive measures and air quality, GIS and mapping. In a special way, we such as hand washing, social distancing, face mask use, also present articles from some of our many risk communication, efficient leadership and decision implementing partners, information on Public Health making. However, we must continue to prioritize our Emergencies and upcoming Health days. environment and public health by continuing to heed all orders from the public health officials. While thanking you, we invite you to share with us your ideas and feedback. Yes, we are excited to hear from Kampala Capital City Authority and our partners will you and ready to extend our Bulletin family. For further continue to serve the public and ensure that we continue information with regards to anything in this bulletin to build a safe and healthy Kampala City. We are proud please contact any of us: [email protected], to associate with this bulletin as it serves as a [email protected] comprehensive source of environment and public health information that is influential for capacity building and Enjoy your reading!! authoritative action by all relevant stakeholders. Thank you.

E D I T O R I A L T E A M

Daniel Ayen Okello Eng. Andrew Kitaka Director Public Health & Environment Ag Executive Director Najib Lukoya Bateganya Kampala Capital City Authority Deputy Director Public Health & Environment

Sarah Zalwango Manager Medical Services

Christopher Oundo Supervisor Medical Services

Alex Ndyabakira Epidemiologist

Elizabeth Katana Epidemiologist

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Public Health & Environment Director's World Blood Donor Day Message 2020 will be remembered as a dynamic year in the world of public health, environment and preparedness for public health emergencies. COVID-19 has presented us with the challenge of responding and adjusting to a modern-day pandemic that has had unique approaches such as institutional quarantine, closing of borders and eventually a lockdown in Uganda. The team at Kampala Capital City Authority has invested significant efforts and resources in the COVID-19 response, environment and public health in general. The activities have spanned from community risk communication, social mobilizations, trainings for staff and health workers, ensuring continuity of essential services in Kampala including operating a toll-free call center to respond to all medical emergencies during the lockdown, prioritizing transportation for mothers in labor, coordination of a public ambulance system, waste management, upscale of water, sanitation and hygiene coverage, assisting vulnerable groups such as street children, community surveillance and tracking of COVID- 19 suspects, among others.

In this inaugural volume and issue of our quarterly public Given these turbulent times of COVID-19 and in health and environment bulletin, we document and observance of the upcoming World Blood Donor Day, present to you key write ups from our efforts, challenges, we should take some time off and donate some blood. and lessons learnt from supporting and sustaining Kampala’s health and environment in the midst of Blood donation is essential because we need to COVID-19. maintain adequate supply in the blood banks as In this turbulent and difficult era of COVID-19, we hope security for the many patients that will need that we have been able to diligently serve, monitor, build transfusions. capacity, communicate, promote public health and nurture a healthy, conducive and sustainable community We can visit the Uganda Blood Transfusion web and environment in Kampala city. This bulletin is a page (https://www.ubts.go.ug/), to find the nearest documentation and communication of our works, place to donate blood in your area. achievements, challenges and advancements to the policy makers, health professionals, the public, Donate blood to save bleeding mothers, cancer implementing partners and all relevant stakeholders. patients, anemic children and accident victims.

Finally, I would like to thank you, the contributors, the readers and editorial team, for your interest in this bulletin and I encourage you to send us your invaluable feedback and ideas. #SAFEBLOOD

Dr. Daniel Ayen Okello SAVESLIVES. Ag. Director Public Health & Environment [email protected]

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Maternal Health Care Management At reduced the human reources due to transport restrictions, KCCA Health Facilities during COVID-19 maternal and child health (MCH) departments retained all their staff to continue with service delivery. Pandemic Authors: *Clara Kokunda 1, Sarah Zalwango 1, Douglas Akii- A functional interfacility referral system was set up where Bua 2, Daniel A. Okello 1 Kisenyi and Kawaala HC IVs were allocated an ambula- 1 Directorate of Public Health and Environment, Kampala Capital City nce due to the client load they handle, averagley 25 to 30 Authority, Kampala, Uganda deliveries per day. For close monitoring of the ambulanc- 2 MaNe Project, Directorate of Public Health and Environment, Kampala e drivers, a register was introduced at the two facilities to Capital City Authority track their movements. Other four ambulances were left *Correspondence: [email protected] mobile to handle the emegercies from other KCCA Background facilities (Komamboga HC III, Kisugu HC II and Kitebi HC Following the declaration of COVID-19 as a pandemic by III). Besides these interevtions, the KCCA MCH depar- the World Health Organization in March 2020, the tment went a head to condcut dialogues with all the 5 Kampala Capital City Authority (KCCA) joined efforts with KCCA maternity centers and 4 PNFP hospitals the Ministry of Health (MoH) and stake holders to prepare (Lubaga Hospital, Mengo Hospital, Nsambya and IHK) to and respond. It is evident worldwide that the response to understand causes of emergecies, complications and COVID-19 requires joint efforts beyond public health delays around maternal /perinatal death reviews. jurisdiction, but rather multi sectoral approaches and collaborations of stakeholders and governments. Lastly, a WhatsApp platform was created to assist in notifying emergency cases; identifying which health facility Following confirmation of the first case of COVID-19 was ready to receive and manage the emergency and to on 21st March 2020, the president and MoH passed request for ambulance services in time. Theatres at directives and guidelines to contain and limit its spread. Kisenyi and Kawaala HC IVs were functionalized and Key directives in Uganda’s COVID-19 lockdown such as boosted to reduce the bulk of emergencies on referral suspension of private and public transport have had an facilities such as Kawempe Hospital and to improve out- effect on access to health facilities and health service comes of emergencies by reducing the time to intervene. delivery. It’s undeniable that all Ugandans have been affected, however, pregnant women, mothers in labor, Results children due for immunization and post-natal mothers As of 7th May 2020, KCCA 24-hour call center had were expected to experience greater challenges in the responded to 1,025 Emergencies and 2,075 community COVID-19 lockdown. To ensure continuity of maternal picks for clients who needed access to routine medical and newborn health services, KCCA put measures to, services such as cancer treatment, dialysis etc. 992 (96%) ensure mothers, especially those in labor, and the of the 1,025 emergencies transported were mater-nal and unborn and the new born children that needed urgent new born health management ie labor, miscarria-ges, and medical attention, were able to access health services immunisation. In regard to the interfacility refer- rals, in the and facilities. month of April alone, a total of 265 referrals from the lower Interventions On March 25, 2020, a 24-hour call center units for further management were made. 27 % of the was set up and disseminated widely to respond to all referrals were from Kitebi HC III, 26% from Kisenyi HC IV, public concerns during the COVID-19 lockdown through a 21% from Kawaala HC IV, 15% from Komamboga HC III toll-free line 0800990000. Clients who called in were and 11% from Kisugu HC III. In a period of four months linked to either ambulance services or community pick up (Jan-April), Kampala registered a total of 25,689 health services with the advice of a clinician. Ambulances were unit deliveries with KCCA contri- buting 34% (8,666). prioritized for emergencies such as mothers in labor while The table below shows a trend community vehicles were utilized for routine services deliveries in Kampala Against KCCA facilities for Jan to including antenatal care services (ANC) and immunizatio- April 2020 ns. Both the ambulances and community vehicles were strategically deployed in different locations across all the five Kampala divisions; like police, health facilities respo- nd to emergencies in a timely manner and all these were offered to the public free of charge. In addition, two vehicles were allocated per facility to transport staff to and from their homes to places of work to ensure there was human resource to respond to the emergencies. Whereas other deparments such as OPD, eye clinic, dental, (continued on next page) PAGE | 03 M E D I C A L S E R V I C E S

Figure 1:Trend of deliveries in Kampala against KCCA system to facilitate remote access, request, deployment HF- Jan to Apr 2020 and tracking of public and private ambulance trans- portation for all medical emergencies including commu- From the dialogue discussion held, two QI projects were nity evacuations to health facilities, and referrals between initiated per facility; to reduce emergency through proper health facilities. Using the ambulance online/digital app- antenatal care and early identification of emergencies lication, all Kampala residents will know all the obtainable during labour through correct use of partogragh to monitor transport options including what ambulance is available, mothers during labor. the services it offers, cost estimates of using it based on Conclusion distances to be covered. All public, private not for profit While COVID-19 has affected Kampala’s medical services and private ambulances in Kampala will be hosted on this in several ways, it has also presented opportunities to real-time Kampala Digital Emergency Transport System. It examine the effectiveness of our health systems and will be linked to the emergency call and dispatch centre approaches as a city. Health facilities will implement set up by KCCA through the MaNe project, to identify best quality improvement projects aimed at early identification positioned health facilities and nearest ambulances to of risky mothers either at ANC or at labor. The risky handle the medical conditions at hand. mothers will be linked to be assessed by specialist either in Kawaala and Kisenyi HC IVs. KCCA plans to scale up The benefits management of maternal health emergencies at all health This innovation will improve emergency medical services facility levels with inter-facility linkage systems in a in Kampala especially through facilitating timely access to phased manner with an aim to reduce patient flow at the transportation from community to health facilities, and higher-level facilities. timely referrals between facilities. This service is also envisaged to improve equitable access to health care. Digital use of Public and Private Ambula- Unlike before and during COVID-19, using this simpli- nce Systems to Increase Timely Access fied application, KCCA is igniting a self-service health to Care during COVID-19 Lockdown and care system where any resident with a health emergency Beyond can directly access a range of ambulances without burea- ucratic procedures. KCCA is aware of cost as a barrier to 1,2 1,2 2 Authors: *Andrew Magunda ,*Henry Kaula , Daniel A. Okello using ambulances by many of the urban slum dwellers 1 Kampala Slums Maternal and Newborn Health (MaNe) Project, Directorate and is planning a public-private partnership to help sub- of Public Health and Environment, Kampala Capital City Authority, sidize the transport of those who can’t afford while public Kampala, Uganda 2 Directorate of Public Health and Environment, Kampala Capital City ambulances hosted on the system will be completely free. Authority, Kampala, Uganda *Correspondence to: [email protected]; [email protected] In addition, Kampala’s medical services are dominated by private health facilities and very few of them own ambu- Background lances. Before and during COVID-19, some of the private Since January 2020, COVID-19 has had several effects facilities may not have been able to attend to some comp- on the health systems of many countries and cities world- licated cases since they cannot easily refer them when wide, Kampala inclusive. Some of the lockdown directives need arises due to lack of ownership or inaccessibility of including curfew and the banning of both private and ambulances. Access to ambulance transport options will public transport have had a significant impact on the therefore give them the confidence and boost to offer care health care system and service delivery. The lockdown to all clients and use this ambulance system during refer- resulted in limited access to Maternal and child health rals. Therefore, the small private clinics won’t be press- services, and care for clients with acute and chronic ured to invest in purchase of ambulances or any other medical illnesses. Consequently, some of the patients vehicles to transport their clients during referrals because who were unable to or delayed to access health care of the assurance that an ambulance will be a click or call during the lockdown either could have died or developed away from reach. complications. These negative ramifications have high- lighted the need for reliable and efficient emergency medical services thus re-emphasizing the extreme Conclusion importance of enhancing digital health technologies for This Kampala digital emergency transport application faster and better health care access and utilization. system is seen as one of major technologically The Innovation innovative responses to improve emergency medical The USAID Kampala Slums Maternal and Newborn services by preparing and launching KCCA into digital Health (MaNe) project and KCCA are developing a digital based health care access to avoid future reoccurrences

(continued on next page) PAGE | 04 M E D I C A L S E R V I C E S amidst possible pandemics, enhance digital access to A deployment plan was established in order to cover health services and reduce typical delays in seeking care areas within a radius of 40 Kilometers from the Kampala for medical and non-medical emergencies in Kampala. city center and this included Mukono, Wakiso and Mpigi. Responses were categorized according as COVID-19 and Coordination of Toll-free Emergency Call non COVID-19 related emergencies. The ambulances Center and Ambulance System during the were reserved for high risk emergencies such as COVID-19 Lockdown in Kampala obstetrics, pediatric, accidents; while community pick up Authors: *Douglas Akii Bua1 , 2, *Doreen O. Alaleit 2, Elizabeth vehicles were reserved for chronic medical conditions Katana2 ,3, Sarah Zalwango2 , Daniel A. Okello2 such as those requiring dialysis, chemotherapy, antenatal 1 Kampala Slums Maternal and Newborn Health (MaNe) Project, Directorate care (ANC) or patient reviews. HIV/AIDS clients were of Public Health and Environment, Kampala Capital City catered for by coordinating delivery of drug refills to their Authority, Kampala, Uganda homes with provision their ART numbers to the Infectious 2 Directorate of Public Health and Environment, Kampala Capital City Authority, Kampala, Uganda Diseases Institute (IDI) team. The call attendants 3 Uganda Public Health Fellowship Program, Ministry of Health, responded to calls using the guidelines set up, the caller Kampala, Uganda would be triaged and according to the condition or *Correspondence to: [email protected]; [email protected] compliant, one of the following steps was taken; 1) Background Medical advice was given through the medical control or Uganda confirmed the first case of COVID-19 on March supervising clinician, 2) The ground surveillance team 21, 2020. In response to COVID-19, amongst other was alerted and linked to the location in case of a interventions, a coordination mechanism through establi- suspected COVID-19 patient, 3) An available ambulance shment of a toll-free call center system was set up at or community pick up vehicle was dispatched to effect KCCA to facilitate rapid case identification, tracing of transport to the nearest health facility or interfacility contacts of confirmed cases and responding to other transfer of clients, 4) All the calls were documented and health emergencies including road traffic accidents, acute daily summaries generated. illnesses, women in labor, among others. This came in Results handy as the lockdown resulted in restricted movement of As of 7th May 2020, KCCA team, the team had public and private vehicles and as such authorized public responded to a cumulative number of 7,681 calls, 882 means of transport including ambulances and community (11.5%) COVID-19 related and 6799 (88.5%) non-related pickup vehicles needed an efficient coordination mecha- calls including 14.6% (992/6,799) as Maternal and nism. The KCCA call center was set up at City Hall on newborn issues, 71.0% (4,830/6,799) were requests for March 25, 2020 utilizing the available resources including ambulances and community pick up vehicles, 3.7% three desk phones and computers with nine dispatchers (249/6,799) calls related to violation of the presidential working in 8-hour shifts. We aimed to ensure the continu- directives, 5.9% (398/6,799) called in asking for food aid ity of essential medical services and to build the public’s among other calls. 30% (1,450/4,830) of the emergency trust in public health authorities during the COVID-19 calls resulted in dispatch of an ambulance service. pandemic. Conclusion Methods The call center has contributed a great deal in keeping Two toll-free numbers were made available and were intact the health care seeking and coordination of medical 0800990000 and 0204660998 and public awareness was emergencies in addition to COVID-19 surveillance and made through constant media coverage, short videos response. This call center can be a benchmark for about the toll-free line and the 24-hour operationalization establishment of other call centers countrywide especially of the services. The call center was manned by team of at the regional referral Hospitals. The call center with all trained personnel that comprised of volunteer social its successes is also registered a number of challenges workers as call attendants, epidemiologists, clinicians and including lack of a switch board in order to be able to or nurses. A training model was developed to train the call receive multiple calls, lack of a tracking system to locate center team with working standard operating procedures the caller and few ambulances are available to respond to and referral guidelines to be used during call processing. the large volume of emergency calls. Software was designed where patient data was captured, triage and sorting of the calls was done to prioritize the Acknowledgements need for urgent medical evacuation. A directory of the St John’s Ambulance Service, Uganda Police Ambulance surveillance teams on ground and the stationed vehicles Service, Nissan Motor Care Uganda and Kiira Municipal and ambulances were made available to the call center Council Ambulance staff.

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The 2ks: Cesarean Sections in Kawaala We did not explore other parameters such as the technique used or the type of anaesthesia given for the and Kisenyi HCIVs during COVID-19 procedures. Data was summarized and analyzed using Pandemic Microsoft Excel. Authors: *Douglas Akii Bua1 , 2, Doreen O. Alaleit 2, Sarah Zalwango 2, Daniel A. Okello 2 1 Kampala Slums Maternal and Newborn Health (MaNe) Project, Directorate Results of Public Health and Environment, Kampala Capital City Authority, There was general increase in the number of the Kampala,Uganda cesarean section cases done at both Health Centers IVs 2 Directorate of Public Health and Environment, Kampala Capital City Authority, Kampala, Uganda with Kisenyi HCIV having more cesareans done. The *Correspondenceto: [email protected] emergency cases by far superseded the elective cases Background especially during the Month of April 2020 for both Since January 2020, the country has registered an facilities. In the period under review, these two facilities upward trend in the maternal deaths with Kampala averted 178 referrals for Cesarean section at Kawempe contributing about 30% of the cases as of March 2020. National Referral Hospital and 95 cases in the month of The maternal death trends in Kampala from the DHIS2 April alone. There was an increasing trend over the indicates a rise in numbers over this period. Some of Months for Kisenyi HCIV as compared with Kawaala with these deaths could be due to delays at the different levels a slight trough in the Month of February 2020 as noted in of care. the figures 1 and 2 below KCCA operates the Public Health facilities of Kitebi HC III, Kisugu HC III, Komamboga HC III, and the two Health Centre IVs of Kisenyi and Kawaala herein referred to as the “2Ks”. These perform deliveries in addition to other maternal, neonatal, child and adolescent health services. The cases that cannot be managed at the 2Ks are often referred to Kawempe National Referral Hospital. Amidst this COVID-19 pandemic, Kampala Capital City Authority(KCCA) upscaled the capacity of these facili- ties to perform caesarean sections through boosting human resource and logistical support. The performance of cesarean section in these facilities will help to reduce the load and waiting time for mothers who would ideally be referred to Kawempe National Referral Hospital and likely improve both the maternal and neonatal outcomes. We sought to determine the extent to which these two Figure 1:Cesarean Sections at Kawaala HCIV for the facilities are performing cesarean sections, representing months of Feb, March and April 2020 referrals to the National referral Hospitals averted. We compared the output from each of the 2Ks in terms of the number of cesarean sections performed and owing to the fact that these two facilities only perform cesarean sections only during day, the cases that require cesarean sections during the night shift are referred. Methods We abstracted data from the theatre registers for the 2Ks for the months of February- to April 2020 with indications for both Elective and Emergency Cesarean Sections. The 2Ks were purposively selected due to their ability to do Cesarean Sections, and the high volumes of cases that are handled. We reviewed all the cesarean section cases irrespective of whether they were referrals in or decisions to perform the cesarean section made at the facility. The facilities were enhanced with catalytic supplies and Figure 2:Cesarean Sections at Kisenyi HCIV for the arrangement to have anaesthetic officers available to months of Feb, March and April 2020 provide safe anesthesia. (continued on next page) PAGE | 06 M E D I C A L S E R V I C E S

Conclusion Intervention Functionalizing the operation theatres at the 2Ks has to a Defeat TB project together with KCCA’s directorate of great extent reduced referral to Kawempe National public health disseminated Ministry of Health COVID-19 Referral Hospital. This shows the capability of these guidelines to all TB treatment centres in Kampala. Using facilities to handle maternal and newborn emergencies the guidelines, health workers were oriented on how to with the output depicted. effectively integrate COVID 19 control measures with TB The 2Ks are delivering these outputs even when the care activities at the facility level. theatres are functional only during the day shift and not at To ensure continuity of TB services during the lockdown, night. Operationalizing of the theatre for 24-hour clients flow and health worker’s role allocation at health coverage will further reduce the referrals to Kawempe facilities was revised. Health workers focused on National Referral Hospital since most of these cases can performing roles essential for effective tracking of TB be handled at the level of Health center IV. The output patients drug refills. Telephone airtime was provided to was even higher at the peak of the COVID-19 outbreak health workers for communicating with patients and amidst all the existing challenges including human between health facilities to ease drug refills. Health resources, equipment and some consumables to enhance workers listed patients due for TB drug refills and operations. reminded them of the refills. Those unable to pick drugs from health facilities due to travel difficulties shared their Guaranteeing Treatment for TB Patients location details. TB drugs were delivered to patients’ in Kampala during the COVID-19 homes or neighborhood using Motorcycles and or Defeat Pandemic in Uganda TB project cars, for those within the radius of 30 Authors: *Herbert Kisamba 1, Sylvia M. Nakibuuka 1, kilometres. Defeat TB supported health workers to review Christopher Oundo2 , Kenneth Mutesasira1 , Abel Nkolo 1, TB drug stock prior to each clinic day. In case of low Daniel A. Okello2 stock, TB drugs were redistributed between facilities to 1 USAID, Defeat TB Project, Kampala, Uganda ensure availability at all health facilities. 2 Directorate of Public Health and Environment, Kampala Capital City For continuity of TB diagnosis services, Defeat TB project Authority, Kampala, Uganda contracted 3 hub riders to reinforce movement of sample *Correspondence: [email protected] from the community and between health facilities. In Background addition, distribution of TB diagnosis logistics like, sputum Tuberculosis (TB) is caused by a bacteria Mycobacterium mugs were done to TB diagnostic units that were running tuberculosis and often affects the lungs. Despite being a low on them. preventable and curable disease, 1.5 million people die from TB worldwide each year – making it the world’s top Key Results infectious killer. According to the World health Access to TB medicines by TB patients remained above Organization, Uganda is among the high burden TB/HIV 80% during the first month of the lockdown for patients countries in the world. About 1 in every 5 TB cases in receiving TB care at KCCA health facilities. At 10 random- Uganda are in Kampala City. Kampala had over 8000 ly selected, high volume TB facilities, the weekly propor- active TB patients and a treatment success rate of 92% tion of patients expected to receive TB drug that received by the end of Jan-March 2020 quarter. USAID Defeat TB them remained high at a weekly average of 88.75% project has since September 2017 been supporting during April 2020 (figure 1). Kampala Capital City Authority (KCCA) to increase TB case notification, case detection, and treatment outcomes through health system strengthening. The world is battling with the COVID-19 pandemic since December 2019 with Uganda reporting a first case in March 2020. Several measures were instituted across the country in response to the pandemic. Among such measures was the national lockdown coupled with the suspension of public transport and restrictions on motorcycle use which could affect TB patients’ access to medicines and adherence to TB treatment. To ensure continued assess to TB medicines and other services, Defeat TB with KCCA initiated specific interventions within Figure 1 Kampala. (continued on next page)

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Figure 1:Trend in expected TB patients receiving Drug This allows immediate deployment of these supplies, also refillsat 10 high volume facilities during April 2020 called Medical Counter Measures (MCMs), as soon as the Similarly, monthly retention of TB patients on treatment PHEs occur.The Covid-19 pandemic has clearly remained comparably high during the first month (April highlighted the importance of MCMs. 2020) of national lockdown as had been during a few Stockpiling is one of the strategies the Ministry of Health months before the lock down (figure 2). (MoH) has established for management of MCMs. This requires health facilities, district stores and central warehouses to have parallel inventory systems that separate MCMs from supplies used for routine services to ensure the MCMs are reserved for PHEs. MoH also has a web-based electronic Emergency Logistics Management Information System (eELMIS) which tracks the location and stock levels of different MCMs throughout the supply chain. COVID-19 is a novel disease and definitely not on the MoH list of priority diseases for PHE preparedness. However, most of the supplies required for its response, such as Personal Protective Equipment (PPE) and dis- infectants, are already among the MCMs required for many other highly infectious diseases on the list, such as the Viral Hemorrhagic Fevers (VHFs), stockpiling well for these probably would have prepared us better for the COVID-19 response. Without stockpiles, the first possible

Figure 2:Trend in expected TB patients receiving Drug option is using supplies for the routine services. This refillsat Kitebi HC III before and during the lockdown approach is limited because many supplies are either not routinely stocked at the health facilities or stocked in small In the process, learning has emerged about; health care quantities owing to much lower need for routine services. worker role allocation, patient locator approaches in the In addition, such diversion can deplete supplies rapidly, community and TB patient support systems in the comm- thereby creating a shortage for the routine services. unity. All this has been useful for provision of TB care Stockpiling overcomes this by ensuring an immediate services. response to a PHE and can be mounted without the need Conclusion to encroach on supplies for routine services. The second The coordinated efforts of KCCA staff and Defeat TB possible option is to order supplies through the National project coupled with cooperation of TB patients has Task Force (NTF), using the eELMIS. This is a system ensured TB patient retention on treatment during the which was set up with ensuring swift ordering and delivery COVID 19 pandemic in Kampala. The lessons learned of supplies as one of its objectives. During the covid-19 will continue to guide TB patient retention in Kampala pandemic, National Medical Stores (NMS) were unable to and other neighboring districts. supply all the items required in sufficient quantities due to the ongoing global logistical shortages and challenges. To Electronic Management of Medical bridge the gap, our third possible option is to undertake Supplies - a Case for Active Stockpiling private procurement. However, commodities are still in for Preparedness short supply and highly overpriced on the market, partly Authors: *Julius Mubiru1 , Elizabeth Katana1 ,2 , Daniel A. due to the breakdown in supply chains as lockdowns were 1 Okello implemented, and panic buying by the public. Once the 1 Directorate of Public Health and Environment, Kampala Capital City Authority, Kampala, Uganda COVID-19 pandemic is contained, it would be wise to 2 Uganda Public Health Fellowship Program, Ministry of Health, Kampala, use any leftover commodities to establish stockpiles of Uganda MCMs. We can utilize the eELMIS and MoH supply chain *Correspondence: [email protected] system to source MCMs that will be used to establish Public health emergencies (PHEs) are usually stockpiling for PHEs to ensure better preparedness. In unpredictable and as such, preparing for them requires addition, we can upscale trainings for supply chain mana- maintenance of stockpiles of medical supplies required for gement of MCMs to health facilities to enable them esta- the response. blish and manage stockpiles in anticipation of PHEs.

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KCCA and Bloomberg’s Partnership for assist Kampala to make public places smoke free, Healthy Cities Strive to Create a healthier and helping the citizens to give up the deadly “Smoke-free” Kampala habit. Authors: *Elizabeth Katana1 ,2 , *Alex Ndyabakira1 ,2 , Angella For more information visit: Nshimye1 , Andrew Kitaka3 , Daniel A. Okello1 partnershipforhealthycities.bloomberg.org 1 Directorate of Public Health and Environment, Kampala Capital City Authority, Kampala, Uganda World No Tobacco Day 2 Uganda Public Health Fellowship Program, Ministry of Health, Kampala, Uganda 3 Executive director’s office, Kampala Capital City Authority, Kampala, Uganda *Correspondence: [email protected] and [email protected] In 2019, KCCA joined the Bloomberg’s Partnership for According to the World Health Organization, Tobacco kills Healthy Cities. This Partnership is supported by more than 8 million people each year. More than 7 million Bloomberg Philanthropies in partnership with the World of those deaths are the result of direct tobacco use while Health Organization and Vital Strategies, a prestigious around 1.2 million are the result of non-smokers being global network of 70 cities including Kampala whose exposed to second-hand smoke. It is estimated that over mayors have committed to saving lives by preventing 80% of the world's 1.3 billion tobacco users live in low- Non-Communicable diseases (NCDs) and injuries and middle-income countries. In commemoration of this including cancer, diabetes, heart diseases and chronic year’s World No Tobacco Day, please continuously lung disease through proven interventions. encourage a smoker to quit. Studies show that when Majority of the world’s population is living in urban settings smokers become aware of the dangers of tobacco, most and 68% of the world is expected to live in cities by 2050. want to quit. WHO urges influencers in pop culture, on NCDs and injuries kill almost 46 million people globally social media, in the home, or in the classroom who reach each year. They are responsible for 80% of global deaths. and connect with youth to expose the tobacco industries’ Through this partnership, cities are uniquely positioned to manipulative tactics to create a new generation of tobacco transform the fight against NCDs and injuries by users. We need to empower youth to stand up to Big implementing policies to significantly reduce exposure to Tobacco by dispelling its lies and refusing to use its risk factors. Cities and their leaders play a critical role in products. developing, implementing and enforcing policies to create health environment for healthier populations. The Effect of COVID-19 Lockdown on Air In this Partnership, each of the 70 member cities including Quality in Kampala city, Uganda. Kampala selected one of the 14 interventions to prevent Authors. Alex Ndyabakira1 ,2 *, Elizabeth Katana1 ,2 , Sadam Yiga 3, NCDs and injuries: create a smoke-free city, ban tobacco Andrew Kitaka4 , Daniel A. Okello2 advertising, raise tobacco taxes or fees, tax sugary drinks, 1 Uganda Public Health Fellowship Program, Ministry of Health, Kampala set nutrition standards for foods served and sold in public Uganda institutions, regulate food and drink marketing, create 2 Directorate of Public Health and Environment, Kampala Capital City healthier environments, reduce speeding, increase Authority, Kampala, Uganda. 3 Executive director’s office, Strategy management and business motorcycle helmet use, reduce drink driving, increase development, Kampala Capital City Authority seat-belt use, promote active mobility, prevent opioid- 4 Executive director’s office, Kampala Capital City Authority, Kampala, associated overdose deaths, public health data and Uganda monitoring systems. *Correspondence: [email protected] According to the Tobacco Atlas, more than 10,637 Background Ugandans are killed by tobacco-caused disease every Exposure to ambient air pollution increases morbidity and year much as smoking is prohibited in Kampala’s public mortality, and is a leading contributor to the burden of places. In its first phase of the partnership, KCCA is many global diseases. In 2016, World Health Organization focusing on creating a smoke-free city with a target to (WHO) estimated that air pollution account- ed for 4.2 reduce the prevalence of smoking in public places by 95% million deaths globally and 36,000 deaths locally. Air by December 2020. We are proud of this partnership as it pollution disproportionately affects cities in the developing has provided technical assistance to this cause, designed world, where pollution levels usually exceed WHO appropriate interventions, communication and public guideline limits. Although many substances are known to relations support, networking and capacity building to potentially contaminate air, the WHO has

(continued on next page) PAGE | 09 P O L L U T I O N & A I R Q U A L I T Y identified carbon monoxide (CO), particulate matter (PM), and 28.1 ± 1.6 μg/m 3 respectively, representing a 41% drop in PM2 levels durin3 g the lockdown. However, the 24- ozone (O 3), nitrogen dioxide (NO 2), and sulfur dioxide (SO2 ) as the pollutants with greatest public health importance. hour mean concentration of PM2.5 during lockdown, 28.1 ± 1.6 μg/m 3 remains above the WHO cutoff of 25 μg/m 3.

WHO relies on the air quality index (AQI) to assess the The mean concentration of NO 2 reduces by 85% during status of ambient air in cities. The ambient air concentra lockdown. Comparing pre-lockdown and lockdown period there was a 34% improvement in air quality in Kampala tions of PM, CO, O 3, NO 2, and SO2 are weighted to construct the AQI. Typically, 50 is the AQI cut off for air city. The mean air quality index during the lockdown considered healthy for all people, and values exceeding period was 117.6, which exceeds 100, the WHO cutoff for 100 are considered unhealthy. PM of diameter <2.5 μm sensitive people. Comparing lockdown period (Apr-May (PM2.5) is considered more hazardous to health than 2020) with the same period of Apr-May 2019, shows that larger PM due to its potential to cross from the lungs into the drop in pollution levels is unique to lock down period. the blood stream. During the COVID-19 pandemic, Uganda instituted multiple measures to reduce the risk of transmission of disease. These included a ‘lockdown,’ starting on 18 March 2020 and modified over time, that drastically reduced the number of automobiles and plants/industries operating in the city. We used this unique opportunity to assess the air quality in Kampala city and the impact of the lockdown. Methods

We assessed AQI, including PM2.5 and NO2 at 25 different sites of different land use areas in Kampala from 1 February to 9 May, 2020. Air pollutant concentrations were measured over 24-hour periods using 25 air quality Figure 1:A graph showing ambient air concentration of monitors of clarity, Node-s (Cellular) model, stationed in PM2.5 against time. such a way to cover different land use patterns in the city. Conclusion The monitors can assess PM2.5 concentrations in the Lockdown due to COVID-19 pandemic resulted in range of 0-1000 μg /m 3, NO in the range of 0-3000 parts 2 immediate significant reduction in ambient air pollution, per billion (ppb), and have real-time temperature and and improved air quality in Kampala city. The sustained humidity gauges in the range of -200C to 70 0C and 0- low air pollution levels throughout the observation period 100%, respectively. The operations of the monitors can be confirm adherence to lockdown restrictions. This visualized on a computer via the internet. Data were demonstrates the significant contribution that automobiles directly downloaded from the monitors through a web and industries make to the air quality in Kampala city. application using a laptop computer. For this analysis, we Emissions controls for automobiles and industries can go used data from the monitoring station at Kampala Capital a long way to reducing air pollution. Strategies that can City Authority (KCCA) headquarters. Data analysis was reduce the number of automobiles and plants/industries in conducted using STATA 13. Kampala city can greatly improve air quality. Results Using the data from the KCCA headquarters monitoring Air Pollution Monitoring in Kampala city station, the mean (± standard deviation (SD)) ambient Authors: *Sadam Yiga1 , Alex Ndyabakira2 ,3, Najib L. Bateganya3 temperature over February-May period was 25.6 ± 0.16 °C ,Daniel A. Okello3 , Andrew Kitaka 4 (maximum 29.4 °C, minimum 21.8 °C). Mean humidity was 1 Executive director’s office, Strategy management and business 71.6% ± 0.61 (maximum 82.9%, minimum 45.0%). development, Kampala Capital City Authority Archived temperature and humidity data from the other 24 2 Uganda Public Health Fellowship Program, Ministry of Health, Kampala Uganda monitors show a similar average temperature and humidity. 3 Directorate of Public Health and Environment, Kampala Capital City The concentrations of PM2.5 show a drastic decline Authority, Kampala, Uganda beginning immediately at lockdown (Fig. 1). The 24-hour 4 Executive director’s office, Kampala Capital City Authority, Kampala, Uganda mean concentration of PM2.5 during the pre-lockdown period (February-March 20th) and during lockdown (Apr- *Correspondence: [email protected] May 8th) period is 51.8 ± 2.9 μg/m3 (continued on next page)

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Clean air is essential for good health, however due to drivers burning fossil fuels in vehicles, industry energy usage, dusty roads, open waste burning among others our air gets polluted with external substances like dust, gases, liquids among others. Air pollution can be both outdoors (outside buildings) and indoor in buildings where we spend time home, offices, hospitals, classrooms among others. To help us understand the risk of air pollution, World Health Organization (WHO) through evaluation of various scientific evidence identified key pollutants with significant impact on human health. Figure 1:Baseline NO 2 levels in selected sites in These include Particulate matter (PM) with sizes less than Kampala city, 2018

2.5 and 10 microns; nitrogen dioxide (NO2 ), ozone (O3 ) With support from European Union, KCCA developed a and Sulphur dioxide (SO2 ) from combustion of fossil fuels in vehicles, industries; dust and open burning of waste. monitoring network to collect data on air pollution and identify sources of air pollution so as to develop Estimates by WHO show that 91% of global population interventions to reduce the emissions for public health and lives in areas with air quality that exceeds the guidelines environment protection. Five air quality monitoring sites limits1 . In addition, 4. 3 and 3.8 million annual deaths are were selected from each of the five divisions of estimated to be due to outdoor and indoor air pollution Kampala, making a total of 25 air quality monitoring respectively 2. Uganda is not an exception to health stations. The sites were selected based on land use impacts caused by poor air quality. In 2016, WHO pattern, level of traffic, access, security and population estimated that Uganda had 13,416 and 23,364 ambient density in the area (Figure 2). and indoor air pollution related deaths 2. The deaths were as a result of diseases caused or exacerbated by exposure to air pollution.

Kampala City is a fast growing City with a resident population of 1.5 million and day population estimated to be 3 million people. This has affected heavily the City’s services through urban planning, pressures on roads by heavy traffic jams, poor waste management, industries in residential areas among others. These factors serve as drivers for air pollution in the City.

A mix of measures by various stakeholders including government, the public and development partners will be required to ensure clean air for Kampala City. Kampala Figure 2:Distribution of continuous air quality monitoring Capital City Authority (KCCA) in collaboration with stations in Kampala Capital City Authority Makerere University and United States government Monitoring air quality and implementing interventions Embassy, have been collecting and analyzing air pollution to reduce pollutant sources are key to achieving clean air data using passive and continuous monitors. The results for Kampala. This will be beneficial to public health but will show high levels of particulate matter 2.5, 10 and NO 2 also improve the City’s competitiveness to attract tourism pollution both exceeding WHO guidelines limits. The and investment opportunities that contribute to improved sources of particulate matter have been identified as dust, local economic development. vehicle emissions and open waste burning. Indoor air pollution is mostly due to use of biomass for cooking. Nitrogen dioxide emissions are mainly from vehicles, and References some stationary sources including industries around the 1 WHO, 2016 Ambient air pollution: a global City. Areas with high traffic in Kampala have high levels assessment of exposure and burden of disease 2 WHO Global health observatory data of NO due to vehicle emissions (Figure 1). 2

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Public Health Emergencies The task force was broad based comprising fifteen members of which six were surveillance officers (among Aside COVID-19 Pandemic, other Public Health them nurses, laboratory & data personnel), two were Emergencies have occurred from January to May 2020. health inspectors/educators, two Data officers, two social Uganda workers, two clinicians (physician and clinical officer) and February 2020, 8 laboratory confirmed cases of yellow one laboratory officer. Response phone numbers for the fever in Bullisa (3), Maracha (1) and Moyo (4); including 4 division medical officers and Kampala Capital City deaths (Case Fatality Rate of 50%) Authority (KCCA) emergency response center toll-free/ hotline numbers were disseminated widely to the commu- Elsewhere nity through mass media and on KCCA website/ social April/May 2020, Ebola Virus Disease in The media platforms, to enhance response to calls and alerts Democratic Republic of Congo on COVID-19 suspects and high-risk travelers. Incoming May 2020, Measles in Burundi community alerts were continuously shared in the division May/April/February 2020, Middle East Respiratory surveillance WhatsApp group and dispatched to the teams Coronavirus (MERS-CoV) in The Kingdom of Saudi to initiate response. In addition, MOH shared a list of high- Arabia risk travelers and contacts of confirmed cases for follow April 2020, Measles in Mexico up. The teams were reconstituted with members from the April/March 2020, Dengue fever in France UPDF to boost the exercise. In the community, the village April 2020, Yellow fever in Ethiopia, Republic of South health team member (VHT) introduced the team to the Sudan household head before surveillance activities could pro- March 2020, Middle East Respiratory Coronavirus ceed. A daily report was com-piled and submitted to the (MERS-CoV) in Qatar KCCA central command center. March 2020, Measles in The Central African Republic By May 7, 2020 we had responded to 205 community February 2020, Dengue fever in Chile alerts, tracked 485 high risk travelers and 14 contacts of January 2020, Middle East Respiratory Coronavirus confirmed cases. We collected 117 samples from comm- (MERS-CoV) in The United Arab Emirates unity alerts, 232 from high risk travelers and 14 from COVID-19 Community Surveillance: contacts of confirmed cases. Experiences from an Urban Setting in Kampala City Authors: *Louis Nyende 1, Yahaya Kayemba 1, Alex Ndyabakira1 , 2, Daniel A. Okello 1

1 Directorate of Public Health and Environment, Kampala Capital City Authority, Kampala, Uganda 2 Uganda Public Health Fellowship Program, Ministry of Health, Kampala, Uganda *Correspondence: [email protected] COVID-19 was declared a global pandemic on March 11, 2020. Uganda confirmed its first case on March 21, 2020. Ministry of Health (MOH) instituted a number of strategies to curb its spread. These included active search for all at risk people such as international travelers and contacts for screening and testing, banning of cross border movement of people, and restrictions on mass gatherings. In the Kampala urban division of Makindye, active COVID-19 community surveillance was initiated on March 23, 2020.

Coordination meetings were hosted routinely and Figure 2:Laboratory personnel picking samples in one of remotely, most of the time via internet on a WhatsApp the urban centers as part of the surveillance activities. platform dubbed “Makindye COVID-19 response team”. The key challenges faced by the teams included incorrect The surveillance activities were part of the division phone numbers that were given by the Ministry of Health COVID-19 response that was coordinated by the division for some of the high-risk travelers and contacts. task force.

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When the team called or sought to verify the number World Malaria Day Message given, the names were different. Some of the contacts switched off their phones and this made tracking difficult. Other contacts out rightly refused sample collection. In the future, for similar epidemics, we should consider upscale of online or remote platforms for adequate planning and trainings for community surveillance teams and enhanced communication strategies that can ensure and promote community acceptability.

Hepatitis Day Message

According to the World Health Organization, in 2018, 6 countries accounted for more than half of all malaria cases worldwide: Nigeria (25%), the Democratic Republic of Congo (12%), Uganda (5%), and Cote d’Ivoire, Mozambique and Niger (4% each). In commemoration of the World Malaria day on 25 April, 2020, the need for continued investment and sustained political commitment for malaria prevention and control was highlighted. During this year’s Malaria day celebrations, WHO underlined the critical importance of sustaining efforts to prevent, detect and treat malaria, alongside all other endemic illnesses such as TB, HIV/AIDS, Typhoid, Hepatitis B, etc. while aggressively responding the COVID-19 pandemic. The Ministry of Health’s National Malaria Control Program (NMCP) has tackled urban malaria control in Kampala city by upscaling interventions that included filling puddles, introducing larvivorous fish in water bodies such as ponds, streams etc., improving drainage, vector control through spraying and use of appropriate insecticide treated nets and advocating for malaria control funding. World Air Quality Awareness Week (May 4-8, 2020) Message Hepatitis B is a potentially life-threatening liver infection caused by the hepatitis B virus (HBV). It is a major global This celebration encourages countries and most especia- health problem, estimated to have resulted in 887,000 lly cities and urban centers such as Kampala to care deaths in 2015. It can cause chronic infection and puts about pollution and air quality. The goal of this year’s people at high risk of death from cirrhosis and liver cancer. celebration was to encourage cities to check their Air A safe and effective vaccine that offers a 98-100% protec- Quality Index (AQI) daily. Kampala Capital City Authority tion against hepatitis B and is readily available country- in partnership with Makerere University and the US wide. Preventing hepatitis B infection prevents the develop- Embassy are closely monitoring Kampala’s air quality in ment of complications including the develop-ment of chro- real time. This is to ensure that we have reliable and nic disease and liver cancer. accessible data that can be used as a vital step to improv- ing Kampala’s air quality and helping city dwellers take actions to protect their health especially in the most polluted areas.

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Upscaling Coverage of Handwashing Achievements Facilities in Response to the COVID-19 The WASH task force ensured that all KCCA facilities (the KCCA headquarters, 8 KCCA Health Centres, 5 Pandemic in Kampala 1 urban division administrative offices, 2 stores, 1 mech- Authors: *Richard Mutabazi 1, Jude Byansi , Alex Ndyabakira1 , 2, Eva Nalwanga1 , Daniel A. Okello1 , anical yard, 1 guest house, employment Bureau) were Najib L. Bateganya 1, Allan Nkurunziza1 installed with hand washing stations and supplied with 1 Directorate of Public Health and Environment, Kampala Capital City water and liquid soap. For each facility a staff was nomi- Authority, Kampala Uganda nated to ensure the hand washing stations are replenish- 2 Uganda Public Health Fellowship Program, Ministry of Health, Kampala, ed with water and soap at regular intervals and all people Uganda accessing the premises were required to wash hands. *Correspondence: [email protected] Standard operating procedures (SOPs) were put in place Background to guide hand washing. In addition, 343 locations across Proper hand washing is known to provide primary the city were identified where hand washing stations were prevention against a wide range of diseases. There is supposed to be installed. These were selected based on indisputable evidence that regular hand washing with high concentration of transient populations. These loca- soap and water or alcohol-based sanitizers prevents the tions included entrances to markets, passenger pick up spread of COVID-19. Improved hygiene through hand points, busy bus stops and taxi stages. All premises washing with soap and water can single-handedly reduce accessible to the public were required to install hand- the risk of diarrhea by (42-48)% (Mbakaya et al., 2017). washing stations at the owner’s cost. These were routine- Following the confirmation of the first case of COVID-19 in ly inspected by KCCA to ensure adherence to the hand- Uganda on 21st March 2020, there have been enhanced washing SOPs. Our actions are attracting both new and campaigns and intervention strategies to improve hand old partners joining in the drive to avail hand washing washing practices among dwellers of Kampala city. This facilities. We are standardising designs for both fixed and article presents the approaches we designed and implem- mobile hand washing stations as new and innovative ented to scale up access to hand washing facilities in designs come up. highly congested urban environments within Kampala By mid-May, out of the 343 points identified, only 75 City. In addition, the authors provide some critical insights (22%) have been successfully installed with Hand on the sustainability of scaling up the hand washing washing stations of capacities ranging from 150- 500 facilities and campaigns during and the beyond COVID 19 litres. The distribution of public hand washing stations in pandemic the city is shown in the map below. It can be observed that there are many hand washing stations, evenly distri- Approaches for Scaling Up the citywide Hand buted across the city compared to the pre-COVID-19 washing Campaign pandemic era. The map does not include private install- First, the Water, Sanitation and Hygiene (WASH) ations. This has resulted into improved hand washing subcommittee of the Kampala city COVID-19 Task Force practices among the people in the city. was established coordinated by the Directorate of Public health and Environment. The task force comprised of environmental health officers, epidemiologists, medical officers, social workers, health inspectors, communication specialists, together with multiple partners. The team made hand washing a priority intervention having been identified as a key COVID-19 prevention measure globally. The key intervention strategies included: Identification of vulnerable communities who included the transient public and communities in the informal settle- ments; mobilization of internal and external resources for implementation of priority interventions; Identifying locat- ions to place handwashing stations in public spaces; Installation program was done in corroboration with the Covid-19 Task forces within each Kampala division.

Figure :The distribution of public hand washing stations in the city (continued on next page) PAGE | 14 S A N I T A T I O N & E N V I R O N M E N T

Conclusion hazardous waste are generated, including infected masks, The coverage of public hand washing facilities at targeted gloves and other protective equipment, together with a points in Kampala city during COVID-19 was low at only higher volume of non-infected items of the same nature. 22%. Nevertheless, the Hand washing practices among Unsound management of this waste could cause Kampala city dwellers have improved remarkably due to unforeseen negative effects on human health and the increased risk communication and social mobilization. environment. The safe handling, and final disposal of this Some of the challenges that we have encountered waste is therefore a vital element in an effective included ensuring consistent and sustained supply of emergency response. The following trends in waste water, poor drainage systems and ensuring that the generation have been observed since restrictions to beneficiary institutions consistently provided amenities contain COVID-19 pandemic were instituted. The case of such as soap amenities such as soap, water, sanitizers Kampala is no different from measures taken by other etc. Beyond COVID-19 pandemic, there is need for cities to respond to the current coronavirus epidemic, innovative strategies to sustain these practices and clustered around six categories: Communication and improve provision of amenities. awareness raising, Workplace and commuting; Social Acknowledgements distance; Vulnerable groups; Local service delivery and Appropriate Technology Centre (ATC), Map Uganda, Support to business. Within its mandate, KCCA has Water Aid Uganda, VIVA CONAGUA, MOVIT Uganda, guaranteed municipal solid waste management, with more Water for People, Uganda Water and Sanitation NGO focus on free collection services in the vulnerable Network (UWASNET), Uganda Hand Washing Initiative, residential parts of the city but not necessarily separated National Water and Sewerage Corporation (NWSC), for specific types of waste. UNICEF, Rotary Uganda and many other partners and community members. References Mbakaya, B. C., Lee, P. H., & Lee, R. L. T. (2017). Hand Hygiene Intervention Strategies to Reduce Diarrhoea and Respiratory Infections among Schoolchildren in Developing Countries: A Systematic Review. International Journal of Environmental Research and Public Health, 14(4). https://doi.org/10.3390/ijerph14040371

Solid Waste Generation Trends during COVID-19 Pandemic in Kampala city Figure 1:Free collection services in the residential parts of Authors: *Joel K. Mwesigye1 , Brian Bukenya1 , Alex Ndyabakira2 , Obed Lutakome 1, Jude B. Zziwa1 , the city to minimize heaps of illegal dumpsites and open burning of unmanaged garbage in Najib L. Bateganya 1 communities 1 Directorate of Public Health and Environment,Kampala Capital City Authority, Kampala, Uganda In addition, landfill-based waste picking activities and 2 Uganda Public Health Fellowship Program, Ministry of Health, Kampala Uganda resource recovery have been suspended. *Correspondence: [email protected]

Introduction World Health Organization (WHO) declared the ongoing COVID-19 a public health emergency of international concern in January 2020. Uganda confirmed the first case on 21st March 2020 and a number of measures were instituted to curb its transmission effective from 19th March 2020. The current COVID-19 pandemic raises new challenges regarding municipal waste management practices and procedures. It is not uncommon that during such an outbreak, many types of additional medical and Figure 2: Wastepickers-free waste disposal operations at Kiteezi Landfill

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Citing adaptability and flexibility in our operations since mid-March 2020 in keeping operations going, more so than following a pre-existing plan, this article aims to explore the solid waste generation trends in Kampala during COVID-19.

1. Reduction in waste generated When the central government banned public/private transportation and instituted a lockdown on 1st April requiring people to stay home, non-essential commercial activities were severely negatively affected. The drastic reduction in commercial activities in the central business (CBD) and surrounding suburbs grossly reduced commer- cial waste generation. Over all, the lock down due to Figure 4: These landfill waste pickers’ smiles didn’t last COVID-19 pandemic has led to 20% reduction in waste long as their work could not continue amidst (fig 1). the COVID-19 public health guidelines Conclusion There has generally been a reduction in solid waste gene- ration during the COVID-19 lockdown in Kampala. Much as this reduction in waste generation is temporary, it could have an impact on the total concentrations of greenhouse gases in Kampala’s atmosphere. On the other hand, the increase in medical waste generated during the COVID- 19 pandemic control such as contaminated masks and gloves, used or expired medications can easily be mixed with domestic non-hazardous municipal solid waste. However, safe management of these should ensure these critical waste materials are segregated, collected, treated Figure 3: Trend in waste collection in Kampala shows a and disposed of separately by competent specialized 20% drop over the last two months (March and April 2020) operators.

2. Increased domestic waste The Impact of COVID-19 Prevention The generation of waste is directly accompanied by the Measures on Markets in Kampala city land use pattern. The stay-home polices policies Authors: *Emilian Ahimbisibwe 1, Jeffrey Drani 1 established in the country, have led consumers to Peter Ssetenda1 , Alex Ndyabakira1 , 2, Najib L. Bateganya1 increase demand for online shopping for home delivery. 1 Consequently, organic and inorganic waste generated by Directorate of Public Health and Environment, Kampala Capital City Authority, Kampala, Uganda households has increased. With limited waste segregation 2 Uganda Public Health Fellowship Program, Ministry of Health, Kampala, at source, mixed non-homogenous waste with low quality Uganda. for recycling is collected for disposal at the landfill. *Correspondence:[email protected]

3. Reduction in waste Introduction recycling Waste resource recovery from collection trucks The coronavirus disease (COVID-19) was first announced and landfills has always been a major source of inputs for in Wuhan city, China and was subsequently imported the recycling industry. As a result of the COVID-19 across the globe. By early May, there were 3.9 million pandemic lockdown, recycling activities were stopped, as cases with 270,720 fatalities (7%). Having declared the authorities have been concerned about the risk of COVID- first COVID-19 case on March 21 2020, Uganda had 121 19 infested waste material spreading among waste cases by May 11th. Ministry of health in Uganda instituted handlers (including recyclers). several measures to prevent the spread of the virus.

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One of the major key measures was to decongest Figure 1. Top & Bottom: A section of Kalerwe Market in Kawempe crowded areas, such as schools, markets, places of Division before the Covid-19 outbreak. This puts the market population at risk of various forms of infections such as, water worship, bars and public transport. In fact, a lockdown and food borne diseases. was finally effected to further restrict movement of people. However, due to the anticipated socioeconomic and wel- In this article we present some of the approaches KCCA fare issues associated with the lockdown, food markets has taken to reorganize the markets and enforce COVID were included among essential services and allowed to 19 measures to reduce risks of transmission and food continue operating, albeit with strict measures guided by contamination. Crowded food stalls were reorganized to the Ministry of Health. These standard operating proce- two-meter distance a part, hand washing facilities were dures (SOPs) included strict observance of social distanc- placed at all market entry points and all markets in ing, hand washing and practicing of safe sanitation. Just Kampala were fumigated against mosquitoes and other like other markets in the countrywide, the markets in crawling insects. It is envisaged the transformation of Kampala mainly deal in agro-based food products from these essential work spaces can be a benchmark for farms and nonfood items. The markets are comprised of making them safer for the vulnerable high population temporary wooden structures and some items are sold on groups that operate therein. bare ground exposing them to potential contamination. The markets tend to attract many people from within and Methods outside Kampala city hence the characteristic overcrowd- We disseminated SOPs on COVID-19 prevention from ing. Besides the numerous vendors and customers, other MOH widely within Kampala city through community categories of people who routinely transact in the markets radios, speakers mounted on media vans, mass and include suppliers, loaders and off loaders of produce/ social media and using posters in all markets. Risk comm- goods, cleaners and members of the market committees. unication was done by a trained team from KCCA head- This has led to an overwhelming market population that quarters. We issued directives on mandatory social dista- strains the existing but inadequate space and sanitary ncing between traders and customers. The City Authority facilities (figure 1). also installed hand washing facilities with soap to the markets and ensured constant water supply to all points at all times. The markets were routinely fumigated and vendors who sleep in the markets were supplied with insecticide-treated bed nets. We used photo voice to document the process. The markets were closely moini- tored and nuisance notices served to the management committees to ensure compliance with the SOPs.

Results Overcrowding has been extensively reduced. Spacing between the vendors has increased to four (4) meters. Easy access and movement within the market setting has been achieved. The market management committees have also been empowered to enforce hygiene measures related to reducing risk of COVID-19 transmission. Road- side market/vending around Kalerwe market was elimina- ted. Improvement in the market sanitation following erect- ion of makeshift stalls especially in Kalerwe market has greatly reduced the risk of food contamination (figure 2).

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Figure 1

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*Correspondence: [email protected]

Both the ‘who’ and the ‘when’ of disease patterns are relative to and often dependent on the ‘where’. Geographic Information Science, Software, Systems (collectively known as GIS) and technologies are one of the response tools epidemiologists use in defining and evaluating the ‘where ‘. In essence, making the location a holy grail in combating the outbreak. The spread of COVID-19 like any other disease is inherently spatial. GIS synthesizes sophisticated algorithms, spatial analysis, geo-statistics and modelling, making its technology a powerful tool for the prediction of disease patterns and parasite ecology associations. Its ability to access, share and utilize satellite and remote-sensing data has made possible even wider understanding of health processes, population and of their links to the environment. This has consequently enabled public health professionals to evaluate and quantify the relationships between health-related variables and enviro- nmental risk factors at different geo-graphical scales. To support the public health response to COVID-19 pandemic , GIS provides a set of tools for surveillance, situational awareness, logistics, and communication. The resultant maps and location intelligence provide deeper understa- nding and insights needed to address rapidly changing conditions around the impacted areas making the invisible visible. In this case, GIS is used to observe, understand and guide response to the pandemic (as shown in figures Figure 2.Top & Botttom Improved spacing between 1 and 2). the established Kalerwe Market stalls Vendors in Nakasero market, Newly

Conclusion The COVID-19 pandemic prevention measures have positively impacted on the sanitation and hygiene of markets in Kampala city thereby reducing the risk of COVID-19 transmission coupled with other WASH related

diseases. However, there is need to design innovative Figure 1: The KCCA Based country monitoring GIS strategies to sustainably maintain the gains achieved such Dashboard as foot operated hand washing containers, effective management of long ques or crowds, improved access to masks, etc.

Leveraging Geographic Information Systems (GIS) to Effectively Respond to Figure 2: The KCCA City wide COVID-19 infections COVID-19 Pandemic in Kampala city. monitoring dashboard by division Authors: *Ivan Bamweyana1 , 3, Elizabeth Katana1 ,2 , Patrick Ojirot 3, Moses K. Atwine 3, Daniel A. Okello1 In a recent vulnerability study by the KCCA GIS 1 Directorate of Public Health and Environment, Kampala Capital City Section, Institution of Surveyors Uganda (ISU) and Authority, Kampala, Uganda Department of Geomatics and land management 2 Uganda Public Health Fellowship Program, Ministry of Health, Kampala, Uganda Makerere University, the vulnerability to COVID-19 in the 3 Directorate of Physical Planning, Kampala Capital City Authority, Kampala, Greater Kampala Metropolitan Area (GKMPA) was scaled Uganda to the parish level as shown in figure 3).

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This was useful for COVID-19 related policy decisions *Correspondence: [email protected] such as distribution of food and relief items during lock down. Communication is an essential and indispensable compo- nent of preparedness and response to public health emergencies. Given many previous public health emerge- ncies over the years, Uganda is now far more prepared than in the past, even when we are more interconnected as a global village with evolved, efficient and better communication systems of the 21st century dubbed as “Cambrian explosion of communications technology” (BNPP Australia, 2017). Communication systems of this era including social media platforms, televisions, radio, Figure 3: Greater Kampala Metropolitan Area COVID-19 mobile phones etc. are by far fast evolving with improved Vulnerability Mapping efficiency, creativity, innovation, multi-sectoral collabo- Emphatically, for a GIS to effectively be used for rations, artistry, curiosity, imagin-nation, personal expre- response, there is need to; i) Map the cases -Map ssion, adaptability, reliability and accessibility compared confirmed and active cases, deaths, and recoveries to with the 20th century technology of the 1900’s. identify where the infections exist and have occurred. ii) Map the spread-Time enabled maps can reveal how 20th century systems were majorly analog and nearly infections spread over time and where you may want to inaccessible by many Africans including post mails, radio, target interventions. iii) Map vulnerable populations- analog TVs, among others. The inefficiency of these COVID-19 disproportionally impacts certain demographics analog communication systems of the 1900s, coupled such as the elderly and those with underlying health with inadequate accessibility in Africa, have been conditions. Mapping social vulnerability, age, and other somehow associated with the poor documentation and factors help you monitor at-risk groups and regions you investigation of large influenza pandemics in the past serve. iv) Map your capacity- Map facilities, employees or including the devastating “Spanish’ influenza of 1918- citizens, medical resources, equipment, goods, and 1919 that is speculated to have wiped out nearly 2 services to understand and respond to current and percent of Africa’s population in just six months (Okeke, potential impacts of the epidemic. v) Communicate with 2012; Phillips, Howard, 2014). The presence of improved maps-Use interactive web maps, dashboard apps, and and efficient communication systems has been recently story maps to help rapidly communicate your situation to appreciated and credited with improving the public health enhance situational awareness. Effective GIS response attention, concern and change in Africa’s HIV/AIDS surveillance systems are therefore pivotal in; providing pandemic of the early 1990’s. early warning systems for public health emergencies, In Uganda’s COVID-19 response, the state leaders, public assess the impact of interventions or evaluate progress health authorities, public and stake holders have engaged towards specied goals, and monitor trends in the in variety of information generation and communication development and proliferation of health threats, informing efforts to continuously inform the general population, the prioritization of issues, allocation of resources, public encourage them, built trust and also monitor the progress health policy and strategies. The leveraging of GIS in of events. Soon as China notified the World Health supporting and closely monitoring the COVID-19 Organization of an outbreak of a pneumonia of unknown response at KCCA can be explored through this link, origin, risk communication efforts were upscaled for https://coronavirus-response-19-ctf-kcca- several weeks to ensure the public could access and use gisservices.hub.arcgis.com/ all the important information before Uganda confirmed her first case of COVID-19 on March 21, 2020. The COVID-19 The Contribution of the 21st Century lockdown has required many Ugandans to adjust Communication Technology in Uganda’s their routines remarkably regardless of social inequalities, Response to COVID-19 economic status, physical and mental incapability, etc. Authors: *Elizabeth Katana1 , 2, Alex Ndyabakira1 , 2, hence the need for rapid generation and routine dissemi- Geoffrey Amanya2 , Richard Migisha 2, Daniel A. Okello1 nation of information. However, we cannot ignore the undeniable positive contribution of the 21st century 1 Directorate of Public Health and Environment, Kampala Capital City communication systems in Uganda’s COVID-19 response Authority, Kampala, Uganda 2 Uganda Public Health Fellowship Program, Ministry of Health, Kampala, and preparedness. Uganda (continued on next page) PAGE | 19 I C T | A C K N O W L E D G E M E N T S

Lately if Ugandans want to freely air out their opinions or Moving forward, public health authorities should consider consume information, they are presented with a wide range upscale of legal channels that can effectively verify infor- of possibilities such as, social media platforms, mobile mation and address the possible negative contribution of phones, landline phones, TV, radio, electronic mail, post these communication systems as we expect communica- mail, etc. The online connected world has presented us with tion technology to probably evolve more in the coming possibilities for growth and instant delivery of commu- decades. Some the COVID-19 response strategies that nication during the COVID-19 lockdown. The Ministry of were not easy to execute such as institutional quarantine, Health (MoH) and government officials frequently and freely self-isolation, contact listing and tracing, etc. can be distribute official and crucial information through social evaluated to cater for the public’s expectations and media platforms such as Twitter and Facebook. The public opinions, to allow better risk commu- nication in a future keeps track of the lockdown and presidential directives at similar epidemic. For successful prevention and manage- the comfort of their homes mainly through Television, ment of future outbreaks, it will be wise and important to radios, web searches and social media platforms. invest in primary and community healthcare systems Digital systems have allowed the continuity of essential formally linked with adoption of some of the 21st commu- services during the lockdown including electronic banking nication technologies such as Whats-App, Facebook, services and payment of utilities, some people are able to Twitter, Email, etc., with deep insight into local public work from home using their personal laptops, online health communication needs, and trainings for community shopping and deliveries, electronic distribution of school health care providers. packages through newspapers and web pages, and many public health surveys and researches have been conduct- References ed through online and web platforms. Improved communi- BNPP Australia. (2017, September 1). The Coming Cambrian cation systems have also contributed positively to the Explosion in Technology. access to quality health care by Ugandans and epidemic BNPP AM - Australia - Institutional and Financial Consultants. response by MoH over the years, with the ability to commu- https://www.bnpparibas-am.com.au/Institutions-Consultants/coming- cambrian-explosion-technology/ nicate risks, diagnose and pick up early warning signals and symptoms of many epidemic prone diseases. The COVID-19 Task Force at KCCA has been able to track contacts of confirmed cases and high risk travelers using GPS locators, utilized Mobile apps like the Go App for data Acknowledgements collection and management, coordinated ambulance dispatches and referrals using online platforms such as WhatsApp, used technology and mobile devices to link health facilities, trainings for health workers and meetings have been conducted successfully on online platforms and also logistics have been managed electronically.

Whilst being able to positively contribute on the COVID-19 response, this evolution of communication systems and complexity of some can also bring forth some negative unintended effects. The spread of rumors, myths, gossip, conspiracies unreliable and false information pauses a challenge on public health efforts that can potentially pull down the positive contribution of some of these platforms. The increased access to health information on several communication platforms has been linked with the recent rise in poor use of medicines such as antibiotics to treat infections leading to antimicrobial resistance which has been a turning point for public health and communica- tions in the 21st century.

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Please visit the KCCA COVID-19 Response Hub https://coronavirus-response-19-ctf-kcca-gisservices.hub.arcgis.com/

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